MM13(E) MADRID AGREEMENT AND PROTOCOL CONCERNING THE INTERNATIONAL REGISTRATION OF MARKS REQUEST FOR THE RECORDING OF A LICENSE (Rule 20bis of the Common Regulations) IMPORTANT 1. This request may be presented to the International Bureau directly by the recorded holder or by the Office of the Contracting Party of the recorded holder or by the Office of a Contracting Party with respect to which the license is granted. 2. One single form may be used to request the recording of a license in respect of several international registrations of the same holder, provided that – the licensee is the same for each of the international registrations, and, – the license applies to all, or to the same, designated Contracting Parties for each of the international registrations, and, – the license concerns all, or the same, goods and services for each of the international registrations. 3. Where the request relates to several international registrations, a fee must be paid in respect of each international registration. World Intellectual Property Organization 34, chemin des Colombettes, P.O. Box 18, 1211 Geneva 20, Switzerland Tel.: (41-22) 338 9111 Fax (International Trademark Registry): (41-22) 740 1429 e-mail: intreg.mail@wipo.int – Internet: http://www.wipo.int MM13(E) – I.08 American LegalNet, Inc. www.FormsWorkflow.com MM13(E) REQUEST FOR THE RECORDING OF A LICENSE For use by the holder This request contains the following number of continuation sheets: For use by the holder/Office Holder’s reference: Office’s reference: 1 2 3 4 3 INTERNATIONAL REGISTRATION NUMBER(S) (several international registration numbers may be indicated, provided that the licensee is the same and that the license concerns all, or the same, goods and services and applies to all, or to the same, designated Contracting Parties) NAME OF THE HOLDER (as recorded in the International Register) LICENSEE (a) Name: (b) Address: (c) Telephone: Fax: E-mail address: 4 REPRESENTATIVE (IF ANY) OF THE LICENSEE Name: Address: Telephone: Fax: E-mail address: MM13(E) – I.08 American LegalNet, Inc. www.FormsWorkflow.com Page 2 5 CONTRACTING PARTIES (a) Contracting Parties with respect to which the license is granted (check one box only): The license is to be recorded for all the Contracting Parties designated in the international registration(s) indicated in item 1; The license is to be recorded for some only of the Contracting Parties designated in the international registration(s) indicated in item 1 (specify those designated Contracting Parties, which must be the same for each international registration): (b) Territorial restriction (if applicable): The license concerns only the part indicated below of the territory of the designated Contracting Party(ies) noted below: If the space provided for is not sufficient, check box and use a continuation sheet WARNING: Australia and Germany have made the declaration provided for by Rule 20bis(6)(a) of the Common Regulations according to which their laws do not provide for the recording of trademark licenses, so that the recording in the International Register of licenses relating to an international registration of a mark has no effect in those countries. China, Georgia, Greece, Japan, Kyrgyzstan, Lithuania, Republic of Korea, Republic of Moldova, Russian Federation and Singapore have made the declaration under Rule 20bis(6)(b) of the Common Regulations according to which, while their national legislation provides for the recording of licenses, the recording of licenses in the International Register has no effect in their territory. Consequently, the formalities required for the recording of a license relating to an international registration of a mark in those countries must be completed directly with their national Office, according to the conditions laid down by their respective legislation. 6 GOODS AND SERVICES WITH RESPECT TO WHICH THE LICENSE IS GRANTED (check one box only) The license is to be recorded for all the goods and services covered by the international registration(s) indicated in item 1; The license is to be recorded for the goods and services indicated below in respect of the international registration(s) indicated in item 1 (specify those goods and services, which must be grouped in the appropriate classes and be the same for each international registration): If the space provided for is not sufficient, check box and use a continuation sheet MM13(E) – I.08 American LegalNet, Inc. www.FormsWorkflow.com Page 3 7 MISCELLANEOUS INDICATIONS (optional) (a) Indications concerning the licensee (as may be required by certain designated Contracting Parties): (i) if the licensee is a natural person, nationality of the licensee: (ii) if the licensee is a legal entity: – – (b) legal nature of the legal entity: State and, where applicable, territorial unit within that State, under the law of which the legal entity is organized: The license is to be recorded as an exclusive license (the license is granted only to one licensee and precludes the holder from using the mark and from granting licenses to any other person); The license is to be recorded as a sole license (the license is granted only to one licensee and precludes the holder from granting licenses to any other person, but does not prevent the holder from using the mark). (c) 8 Duration of the license: SIGNATURE BY THE HOLDER OR HIS REPRESENTATIVE Holder (as recorded in the International Register) Name: Name: Signature: 9 Representative of the holder (as recorded in the International Register) Signature: OFFICE PRESENTING THE REQUEST (where applicable) Name of the Office: Signature and/or stamp of the Office: MM13(E) – I.08 American LegalNet, Inc. www.FormsWorkflow.com Page 4 FEE CALCULATION SHEET (a) INSTRUCTIONS TO DEBIT FROM A CURRENT ACCOUNT The International Bureau is hereby instructed to debit the required amount of fees from a current account opened with the International Bureau (if this box is checked, it is not necessary to complete (b)). Account number: Holder of the account: Identity of the party giving the instructions: (b) AMOUNT OF FEES; METHOD OF PAYMENT Amount (177 Swiss francs) × (per international registration mentioned in item 1) Grand total (Swiss francs) Identity of the party effecting the payment: WIPO receipt number Payment received and acknowledged by WIPO Payment made to WIPO bank account IBAN No. CH51 0483 5048 7080 8100 0 Credit Suisse, CH-1211 Geneva 70 Swift/BIC: CRESCHZZ80A Payment made to WIPO postal account IBAN No. CH03 0900 0000 1200 5000 8 Swift/BIC: POFICHBE MM13(E) – I.08 Payment identification dd/mm/yyyy Payment identification dd/mm/yyyy American LegalNet, Inc. www.FormsWorkflow.com CONTINUATION SHEET MM13(E) – I.08 No: .......... of .......... American LegalNet, Inc. www.FormsWorkflow.com